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How Do Actuaries Model Healthcare Costs? Learn the Step-by-Step Process to Project an Employer-Sponsored Health Plan's Spend.

Step 1: Gather Historical Data... 24-36 months of claims data (both paid and pending claims) along with monthly plan member enrollment data

Step 2: Calculate the Historical Per Member Per Month (PMPM) Cost

Step 3: Apply Trend incorporating medical cost inflation, utilization changes, new treatments/drugs and regulatory changes

Step 4: Adjust for Plan Design Changes such as changing the deductible and total cost share, using a narrow network or benefit enhancements

Step 5: Exclude High Cost Claimants

Step 6: Adjust for Demographic Changes within the population

Step 7: Add a Risk Margin of 2-5% to allow for error

Step 8: Benchmark the PMPM against other similar groups and create three final PMPMs: High, Mid and Low estimates of healthcare costs.

Sources:
https://www.soa.org/resources/researc...

https://www.soa.org/4a0244/globalasse...

https://axenehp.com/building-actuaria...

https://www.alseib.org/PDF/Open/Retir...

https://us.milliman.com/en/insight/ph...

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